The association between individual, community and district level factors and the utilisation of maternal health services covering three aspects of maternal health care-use of antenatal care, skilled attendance at delivery and postnatal care were examined in this study. The use of maternal health services in Madhya Pradesh state remains low in comparison with many other Indian states. For example, the analysis in this study showed that 61.7% women received any ANC, 49.8% women received skilled attendance at delivery and 37.4% received any PNC within two weeks of delivery in Madhya Pradesh. The DLHS-3 showed that Kerala had almost universal coverage in the use of maternal health services, including ANC (99.8%) and the use of skilled attendance at delivery (99.4%). Similarly, high figures were found in the states of Tamilnadu and Andhra Pradesh .
The multilevel analysis has shown that individual-level, community-level and district-level factors are important factors associated with the use of maternal health care services in Madhya Pradesh state of India. The multilevel framework demonstrated significant community and district variations in the use of maternal health services. However, the district level variables used in this analysis were not found to be the influential factors for the use of maternal health services. Some of the variables found to be significant in univariate model became insignificant when adjusted for other variables in the multilevel analysis. A study on influence of community-level characteristics on the use of maternal and reproductive health services conducted in Uttar Pradesh state of India reported strong community-level influences on service use, although the type of community effect varied by service type. This study further highlighted that the role of some individual and household factors in determining a person's use of services was mediated by the characteristics of the community in which the individual lives. The results of this study demonstrated the need to look beyond individual factors when examining health-care seeking behavior .
The results of our study showed very strong positive influence of higher household socio-economic status on the use of all three indicators of maternal health services. Previous studies have also reported a positive association between socio-economic status and antenatal care, skilled attendance at delivery and postnatal care [13, 15, 27–30].
Findings regarding high influence of higher education levels of women on the use of maternal health services are consistent with other studies in India and other countries; the better educated women are, more aware about their health, know more about availability of maternal health care services and use this awareness and information in accessing the health care services [14, 15, 29, 31, 32]. Education of husband might be playing a similar role in supporting the women's access to the health services. In the rural areas of the state, maternal health services are delivered through government run CHCs, PHCs and Sub Health Centres. In urban areas, these services are rendered by medical colleges, district and civil hospitals and urban health posts. Maternal health services from private hospitals, nursing homes, health centers and private practitioners are also availed in rural and urban areas. Access to and availability of health care services is expected to be greater in the urban areas. The findings of our study regarding stronger influences of urban residence on the use of ANC services and skilled assistance at delivery are consistent with the results of previous studies [15, 27, 30]. No considerable differences in the use of skilled attendance at delivery were found between employed and unemployed women.
Religion and cast showed considerable influences on the use of ANC and safe delivery services whereas no noteworthy influence of these factors was found on post natal care in our study. A multi state study conducted in southern India demonstrated that caste had varied influence on the use of maternal health care services in different states; for example, this study reported that belonging to a lower caste was a stronger correlate of institutional delivery in Andhra Pradesh while in other states being a member of scheduled caste or tribe reduced the likelihood of using maternal health services . Influence of religion and caste on the use of maternal health services needs to be further investigated. The findings of our study suggest that the use of ANC had a noteworthy effect on the use of skilled attendance at delivery and the use of both ANC and skilled attendance at delivery had considerable influence on the use of PNC. Another study conducted in rural India also recorded similar findings . Our study found that the use of PNC was not much influenced by the place of residence. This may be because all women who deliver their babies in health facilities are given PNC before discharging them and providing or seeking PNC is negligible in the cases of home deliveries regardless of residence in urban or rural area.
This study showed no substantial influence of the ratio of PHC to population at district level on the use of maternal health services. This might be because the districts which have larger numbers of residents per PHC also have better presence of private health facilities. A study conducted in Madhya Pradesh in 2007 reported that out of 24,807 qualified doctors and 94,026 qualified paramedical staff mapped in the survey in the state, 18,757 (75.6%) and 67,793 (72.1%) were working in the private sector respectively . Apart from these qualified medical and paramedical personnel, a huge network of unqualified practitioners also constitutes a huge part of private sector health care in the state. The role of private health care providers in influencing the use of maternal health services needs to be further studied. It is also surprising that despite having high shortfall of health facilities and human resources for health care in tribal areas of the state, no noteworthy influence of percent tribal population in the district of residence was found on the use of maternal health services. This issue needs to be further investigated. Further research is also required to identify the district level factors associated with the use of maternal health services as none of the variables used in this study at this level were found to be influential. The role of economic development, population-health personnel ratio, status of gender equity and women's empowerment at district level may be explored in this regard.
The findings of our study have implications on evidence based programming for maternal health care. These findings highlighted the need of adopting multilevel approaches along with addressing the factors affecting the use of maternal health services at individual, community and district levels. The amount of variation at community and district level found in our study indicates the need to contextualize efforts for increasing the use of maternal health services. Our study also revealed the existence of some unmeasured factors at community and district level influencing the utilisation of maternal health services. Hence, adopting district specific strategies along with identifying and addressing district level factors affecting the use of maternal health services would give better results.